Quality Improvement (QI) Remains a Central Theme at HM13


Instructor Ketino Kobaidze, MD (left) of Emory University School of Medicine in Atlanta reviews ultrasound techniques with William Levin, MD, of the University of Pittsburgh.

John Bulger (center) leads small-group discussion during HM13's Choosing Wisely quality pre-course.

John Bulger (center) leads small-group discussion during HM13’s Choosing Wisely quality pre-course.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

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